dr. osama el shahat pd in dm

PD In Diabetic Patients

Dr. Osama El-ShahatDr. Osama El-Shahat Consultant Nephrologist

Head of Nephrology Department New Mansoura General Hospital

(international()Egypt(

AgendaAgenda

Introduction PD in diabetic Patients :

PD membrane PD Fluids Education Potential advantages Concerns

Insulin requirements in PDInsulin requirements in PD Conclusion

Diabetes mellitus: factsfacts

By the year 2030 366 million people (4,4% vs. 2,8% now)

Caused by genetic, environmental factors, chronic subclinical inflammation

Enhanced cardiovascular morbidity and mortality: especially in females

About one third of the new patients About one third of the new patients receiving dialysis treatmentreceiving dialysis treatment

Diabetes as the primary diagnosis ofDiabetes as the primary diagnosis ofincident renal replacement treatmentincident renal replacement treatment

patients in 2000patients in 2000

PrinciplesPrinciples ofof PDPD

Dialysis fluid is introduced to the peritoneal cavity through a catheter placed in the lower part of the abdomen.

peritoneum serves as the dialysis membrane. The peritoneal cavity can often hold more then 3 litres, but in clinical practice only 1.5 – 2.5L of fluid are used.

Solutes are transported across the membrane by diffusion.

Fluid is removed by ultrafiltration driven by an osmotic pressure gradient.

PD fluidsPD fluids

Glucose :Glucose was the only osmotic agent available until 1990.

It is not directly toxic, effective and inexpensive available in con. 1.36% 1.5% 2.2% 3.86 and 4.25% with high glucose concentration is used for effective UF

Sitter T.PDI 2005; 25;415-25Sitter T.PDI 2005; 25;415-25

Diabetes mellitus and PDDiabetes mellitus and PD: :

PhysionealPhysioneal↓↓ Infusion painInfusion pain↓↓ PeritonitisPeritonitis↑↑ Glycemic controlGlycemic control↑↑ AppetiteAppetite↑↑ Patient acceptancePatient acceptanceNo No ↓↓ UF UF

PhysionealPhysioneal↓↓ Infusion painInfusion pain↓↓ PeritonitisPeritonitis↑↑ Glycemic controlGlycemic control↑↑ AppetiteAppetite↑↑ Patient acceptancePatient acceptanceNo No ↓↓ UF UF

Icodextrin Icodextrin ↓↓ Glucose load Glucose load ↑↑ Glycemic controlGlycemic control↑↑ UF, control of fluid statusUF, control of fluid status↓↓ DyslipidemiaDyslipidemia↑↑ Quality of lifeQuality of life↑↑ Time on PDTime on PD

Icodextrin Icodextrin ↓↓ Glucose load Glucose load ↑↑ Glycemic controlGlycemic control↑↑ UF, control of fluid statusUF, control of fluid status↓↓ DyslipidemiaDyslipidemia↑↑ Quality of lifeQuality of life↑↑ Time on PDTime on PD

Pecoits-Filho, et al. Kidney Int. 2003;64(suppl 88):S100-S104.Vardhan, et al. Kidney Int. 2003;64(suppl 88):S114-S123.

NutrinealNutrineal↓↓ Glucose loadGlucose load↑↑ Glycemic controlGlycemic control↑↑ Protein intake, nutritional statusProtein intake, nutritional status

NutrinealNutrineal↓↓ Glucose loadGlucose load↑↑ Glycemic controlGlycemic control↑↑ Protein intake, nutritional statusProtein intake, nutritional status

NNewew PD PD solutionssolutions

Icodextrin Icodextrin andand fluid status fluid status

Diabetes mellitus and PeritonealDiabetes mellitus and PeritonealDialysis: Dialysis: potential advantagespotential advantages

No need for vascular access No need for systemic anticoagulation Continuous therapy Gradual ultra filtration Better preservation of renal function Fewer episodes of hypotension Better control of anemia Lifestyle advantages More liberal diet

Diabetes and peritoneal dialysis: What about RRF?

Diabetes and peritoneal dialysis: What about RRF?

ARB’s and PD and RRF

PD in diabetics: concerns

About Differences in peritoneal membrane structure?

Higher peritonitis rates?

About morbidity and mortality

Physiology of Peritoneal Transport

Peritoneal blood folw50-100 ml/min.

bloodwater

ultrafiltrationUrea,Cr

Electrolyte

diffusion

Abd. carvity

Diffusion is depend on dialysatenot depend on peritoneal blood flow

Diabetes and peritonealmembranemembrane characteristicscharacteristics

PDC- parametersdiabeticsdiabetics vsvs nonnon diabeticsdiabetics

Diabetic patients probably have a larger vascular surface area,

potentially related to neo-angiogenesis have a more leaky membrane, probably due to interstitial damage

Diabetic patients probably have a larger vascular surface area,

potentially related to neo-angiogenesis have a more leaky membrane, probably due to interstitial damage

Nakamoto *multiplied by 10 et al, AJKD, 2002Nakamoto *multiplied by 10 et al, AJKD, 2002

Diabetes Diabetes andand peritonitis risk peritonitis risk

Diabetes mellitus and PD: Diabetes mellitus and PD: determinants of survival: the role of inflammationdeterminants of survival: the role of inflammation????

ConclusionsConclusions Peritoneal dialysis seems to be associated with 48% lower mortality than

hemodialysis over the first 2 years of dialysis therapy independent of

modality switches or differential transplantation rates.

Clin J Am Soc Nephrol 8: 619–628, 2013Clin J Am Soc Nephrol 8: 619–628, 2013. .

Quellhorst et al, JASN 2002Quellhorst et al, JASN 2002

Insulin therapy in ESRDInsulin therapy in ESRD

Impact of education on diabeticcompliance

Intensive counseling of diabetic patients on PD :

Importance of salt restriction

Importance of glucose monitoring

Deleterious effect of high glucose solutions

Quan and Wang T. et al, PDI 2006Quan and Wang T. et al, PDI 2006

Impact of education on diabeticcompliance

After 1 year:

Compliance to salt restriction increased from 19.5 to 76.2 %

Only 3/31 used 2.5% and 1/31 used 4.25%

Fluid status improved as measured by bio-impedance measurement

Quan and Wang T. et al, PDI 2006Quan and Wang T. et al, PDI 2006

SAGE-Hindawi Access to Research International Journal of Nephrology Volume 2011, Article ID 914849, 10 pages doi:10.4061/2011/914849

SAGE-Hindawi Access to Research International Journal of Nephrology Volume 2011, Article ID 914849, 10 pages doi:10.4061/2011/914849

Conclusion

No doubt that diabetes is an evil disease, with negative impact on outcome of ESRD patients

PD in an integrated care approach is a suitable alternative for diabetics

Attention to preservation of RRF Blood Sugar control Use of ARABs Low –GDP mandatory Patient education and training

Do glucose free solutions leadDo glucose free solutions leadto to better glycemia controlbetter glycemia control??

Daily insulin requirements for diabetic patients on peritoneal dialysis